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Updated Guideline on Diagnosis and Treatment of Intra ...

694 American Family Physician Volume 82, Number 6 September 15, 2010 Coverage of guidelines from other organizations does not imply endorsement by AFP or the infections are the second most com-mon cause of infectious mortality in intensive care units. Complicated Intra -abdominal infection, which extends into the peritoneal space, is associated with abscess for-mation and peritonitis. Uncomplicated infection, which involves intramural inflammation of the gastrointesti-nal tract, may progress to complicated infection if left untreated. Treatment of Intra -abdominal infections has evolved in recent years because of advances in supportive care, diagnostic imaging, minimally invasive intervention, and antimicrobial therapy. Based on this new evidence, the Surgical Infection Society and the Infectious Dis-eases Society of America recently Updated recommen-dations for Diagnosis and Treatment of these infections.

Sep 15, 2010 · if a common community isolate (e.g. ... Empiric antibiotic therapy for health care–associated ... and management of complicated intra-abdominal infection in adults and children: guidelines by ...

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1 694 American Family Physician Volume 82, Number 6 September 15, 2010 Coverage of guidelines from other organizations does not imply endorsement by AFP or the infections are the second most com-mon cause of infectious mortality in intensive care units. Complicated Intra -abdominal infection, which extends into the peritoneal space, is associated with abscess for-mation and peritonitis. Uncomplicated infection, which involves intramural inflammation of the gastrointesti-nal tract, may progress to complicated infection if left untreated. Treatment of Intra -abdominal infections has evolved in recent years because of advances in supportive care, diagnostic imaging, minimally invasive intervention, and antimicrobial therapy. Based on this new evidence, the Surgical Infection Society and the Infectious Dis-eases Society of America recently Updated recommen-dations for Diagnosis and Treatment of these infections.

2 The new Guideline includes recommendations for treat-ment of Intra -abdominal infections in children, man-agement of appendicitis, and Treatment of necrotizing enterocolitis in Evaluation Routine history, physical examination, and labora-tory studies will identify most patients who require further evaluation. Intra -abdominal infection should be considered in patients with unreliable physical examination findings ( , those with impaired mental status or spinal cord injury) who present with evidence of infection from an undetermined source. Further diagnostic imaging is not necessary in patients with obvi-ous signs of diffuse peritonitis and in whom immediate surgical intervention is required. Computed tomography (CT) should be performed to determine whether an Intra -abdominal infection is present in adults who are not undergoing immediate ResuscitationRapid restoration of intravascular volume should be undertaken, as should any additional measures necessary to promote physiologic stability.

3 In patients with sep-tic shock, resuscitation should begin immediately after hypotension is identified. In patients with no evidence of volume depletion, intravenous fluid therapy should begin as soon as Intra -abdominal infection is source control procedure to drain infected foci, control ongoing peritoneal contamination, and restore anatomic and physiologic function is recommended in virtually all patients with Intra -abdominal infection. Emergency surgery should be performed in patients with diffuse peritonitis, even if measures to restore physi-ologic stability must be continued during the procedure. An urgent approach also should be taken in hemo-dynamically stable patients without evidence of acute organ failure. However, intervention may be delayed for up to 24 hours in closely monitored patients who have started antimicrobial therapy. Select patients with mini-mal physiologic derangement and a well-circumscribed focus of infection can be treated with antimicrobial therapy without a source control procedure if close clini-cal follow-up is patients with severe peritonitis, relaparotomy is not recommended in the absence of intestinal discontinu-ity, abdominal fascial loss that prevents abdominal wall closure, or Intra -abdominal EvaluationRoutine blood cultures and Gram stains are not rec-ommended in patients with community-acquired Intra -abdominal infection.

4 Anaerobic cultures are not Updated Guideline on Diagnosis and Treatment of Intra -abdominal InfectionsCARRIE ARMSTRONGG uideline source: Surgical Infection Society, Infectious Diseases Society of AmericaLiterature search described? YesEvidence rating system used? YesPublished source: Clinical Infectious Diseases, January 15, 2010 Available at: Guidelines Downloaded from the American Family Physician Web site at Copyright 2010 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact for copyright questions and/or permission Guidelines698 American Family Physician Volume 82, Number 6 September 15, 2010necessary in these patients if empiric antimicrobial ther-apy is provided. However, routine aerobic and anaerobic cultures may be of value in determining resistance pat-terns and follow-up oral therapy in lower-risk patients with community-acquired infection.

5 In higher-risk patients, cultures should be obtained from the infection site, particularly in those with previ-ous antibiotic exposure. The specimen should be repre-sentative of the material associated with the infection and should be of sufficient volume (at least 1 mL). For optimal recovery of aerobic bacteria, 1 to 10 mL of fluid should be inoculated directly into an aerobic blood cul-ture bottle. In addition, mL of fluid should be sent to the laboratory for Gram stain testing and, if indicated, fungal cultures. If anaerobic cultures are requested, at least mL of fluid or g of tissue should be placed in an anaerobic transport tube. Alternately, 1 to 10 mL of fluid can be inoculated directly into an anaerobic blood culture culture and susceptibility studies should be performed in patients with perforated appendicitis or other community-acquired Intra -abdominal infection if a common community isolate ( , Escherichia coli) is resistant to antimicrobials in widespread local use.

6 Susceptibility testing should be performed for Pseudo-monas, Proteus, Acinetobacter, Staphylococcus aureus, and predominant Enterobacteriaceae (as determined by moderate-to-heavy growth), because resistance is more likely in these organisms. Antimicrobial TherapyAntimicrobial therapy should be started as soon as Intra -abdominal infection is diagnosed or suspected. Antibiot-ics should be administered as soon as possible in patients with septic shock. Those who do not have septic shock should begin antimicrobial therapy in the emergency department. Adequate drug levels should be maintained during the source control procedure, which may neces-sitate additional administration of TO MODERATE COMMUNITY-ACQUIRED INFECTION IN ADULTSA ntibiotics used for empiric Treatment of community-acquired Intra -abdominal infection should be active against enteric gram-negative aerobic and facultative bacilli and enteric gram-positive streptococci.

7 Coverage for obligate anaerobic bacilli should be provided for dis-tal small bowel, appendiceal, and colon-derived infection and for more proximal gastrointestinal perforations in the presence of obstruction or paralytic adults with mild-to-moderate community-acquired infection, the use of ticarcillin/clavulanate (Timentin), cefoxitin, ertapenem (Invanz), moxifloxacin (Avelox), or tigecycline (Tygacil) as a single-agent therapy, or a com-bination of metronidazole (Flagyl) with cefazolin, cefu-roxime, ceftriaxone (Rocephin), cefotaxime (Claforan), levofloxacin (Levaquin), or ciprofloxacin (Cipro) is pref-erable to regimens with substantial antipseudomonal activity (Table 1). Ampicillin/sulbactam (Unasyn) is not recommended because of high resistance rates in community-acquired E. coli. Cefotetan and clindamycin (Cleocin) are not rec-ommended because of increasing resistance among the Bacteroides fragilis group.

8 Aminoglycosides are not rec-ommended for routine use in adults with community-acquired Intra -abdominal infection because less toxic agents are available that are equally COMMUNITY-ACQUIRED INFECTION IN ADULTSP atients with severe community-acquired Intra -abdominal infection should be treated empirically with antimi-crobial regimens that have broad-spectrum activity against gram-negative organisms, such as meropenem (Merrem), imipenem/cilastatin (Primaxin), doripe-nem (Doribax), or piperacillin/tazobactam (Zosyn) as single agents, or a combination of metronidazole with ciprofloxacin, levofloxacin, ceftazidime (Fortaz), or cefepime (Maxipime; Table 1). A combination of aztreo-nam (Azactam) and metronidazole is an alternative, but the addition of an agent effective against gram-positive cocci is routine use of aminoglycosides is not recom-mended unless there is evidence that the patient harbors resistant organisms.

9 The use of agents effective against methicillin-resistant S. aureus (MRSA) or yeast is not recommended unless there is evidence of infection with these organisms. Quinolone-resistant strains of E. coli are common in some communities; therefore, quinolones should not be used unless hospital surveys indicate more than 90 percent susceptibility of E. coli to these agents. HEALTH CARE ASSOCIATED INFECTION IN ADULTSE mpiric antibiotic therapy for health care associated Intra -abdominal infection should be driven by local microbiologic results. To achieve empiric coverage of likely pathogens, multidrug regimens that include agents with expanded activity against gram-negative aerobic and facultative bacilli may be necessary (Table 2). Broad-spectrum antimicrobial therapy should be tailored when culture and susceptibility reports become AND CHOLANGITIS IN ADULTSA ntimicrobial therapy should be initiated in patients with suspected infection and acute cholecystitis or chol-angitis (Table 3).

10 However, anaerobic therapy is not indicated unless a biliary-enteric anastomosis is present. September 15, 2010 Volume 82, Number 6 American Family Physician 699 Practice GuidelinesIf the patient is undergoing cholecystectomy for acute cholecystitis, antimicrobial therapy should be discontin-ued within 24 hours unless there is evidence of infection outside the wall of the IN CHILDRENR outine use of broad-spectrum antimicrobial agents is not indicated in children with fever and abdominal pain unless complicated appendicitis or other acute Intra -abdominal infection is suspected. Selection of antimicro-bial regimens should be based on the origin of infection (community versus health care), severity of the illness, and safety profiles of the antimicrobial agents in broad-spectrum antimicrobial regimens for children with complicated Intra -abdominal infec-tion include aminoglycosides, carbapenems (imipenem/ cilastatin, meropenem, or ertapenem), combined beta- lactam antibiotics or beta-lactamase inhibitors (piperacillin/tazobactam or ticarcillin/clavulanate), and advanced-generation cephalosporins (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metroni-dazole (Table 1).


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